Diseases, Disorders information

Superficial nonanatomic tenderness, if you touch the patient very lightly and they have exquisite pain, stimulation rotation, if you basically have the patient stand up and rotate the shoulders and the hips together, you are log-rolling them, you are not putting any torsion movement on the spine, if they say they have back pain, where there’s really not a physiologic reason for that, so that would be a positive simulation rotation; axial compression, you put direct compression down on the head, the patient complains of neck pain, that is fine, they complain of back pain, the really shouldn’t because unless you are extraordinarily strong, you are not putting a load on the lower back by compressing the head. Distraction maneuver, straight leg raising maneuver should produce the same results whether the patient is seated or recumbent, regional motor or sensory dysfunction, that’s the stocking glove loss or over reaction. Now as these things were validated, two of the five are still compatible with organic pathology, and that makes sense because you can get a stocking sensory deficit and a peripheral neuropathy with diabetes, so that makes sense. Three of the five, you start to get a little nervous, four would suggest some somatic overlay, five has theological overtones regarding the second coming and inability to have a cure.
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As we move away from physical examination, the treatment of course, is something in which we are very interested and how would you approach these patient’s initially. Well, the lumbar series, we talked about that, certainly in someone over the age of 45, and again, that’s predominantly the rule at a gross lytic lesion. A brief period of bed rest, the current wisdom in that is no more than 48 to 72 hours, Sam Weasel who is at Georgetown did a study in military recruits 100% compliance in that study population, and found that in fact, 48 hours was the optimum duration to shorten the natural history or the duration of the acute flare-up. Traction absolutely of no value whatsoever. A patient, just to overcome soft tissue restraints at the lumbosacral junction, takes about 40% of body weight and trying to administer that force in a reproducible way is very difficult. There are some instruments that are commercially available now, the so-called Vacs Detraction table which is attempting to deliver the force more accurately, but good prospective data on efficacy are notably lacking in that instance.
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Supports: Very, very limited roll, you have probably seen in your institution these kind of belt-like supports with the shoulder straps, well, guess what, if you did flexion extension x-rays on those patient’s, you would see those supports limit range of motion, so they are biomechanically useless and there are some studies that suggest psychologically it might not be the greatest thing to do because the patient has more of a sense of invincibility with in fact, what is a very token support in the biomechanical sense.